Authors: Oscar Lyons1, Alan Hasanic2, Rounaq Nayak3, Ivan Spehar4
Affiliations:
IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders
IMproving Performance And Care in Teams (IMPACT)
supplementary text and tables to accompany poster presentation
Contents
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Introduction
Methods
Results
Conclusions
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
2. Background
Senior NHS leaders have been increasingly required to meet greater challenges. Implementation of change is difficult to achieve in complex environments such as healthcare systems (1). Even simple healthcare innovation projects have proven to be challenging, with the success rates of implementing quality improvement (QI) initiatives estimated at less than 50% (2).
Regardless, political pressure exists for senior management teams to achieve ambitious targets, such as increasing elective activity to 30 percent greater than pre-pandemic levels within three years (3) Internationally, there has been some success with empowerment of clinical “triumvirates” of managers, senior doctors, and senior nurses to produce solutions to quality improvement problems (4).
The IMPACT (Improving Performance and Care in Teams) programme was conceived and designed by Oxford University Hospitals NHS Trust to help address difficulties in implementing change. While leadership development programmes for senior healthcare leaders have increased in number over recent years, it is still unclear how success should be defined for healthcare leadership development programmes, and how this can best be achieved (5).
In this study we interviewed participants to explore both how they define success in healthcare leadership development programmes, and the core programme factors that they felt were necessary to successfully achieve success in healthcare leadership development programmes.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
3. Methods
Programme design
The IMPACT programme was a 12-month leadership development programme for senior management triumvirates at Oxford University Hospitals (Matrons, Clinical Directors, Operational Service Managers). The IMPACT programme consisted of workshops every two months, delivered at a nearby conference centre. These workshops aimed to engage and empower triumvirates through supporting them with leadership development material. Alongside the formal programme, there were two internal strategic improvement consultants working with teams to help them achieve their goals. The programme used the NHS Healthcare Leadership Framework to guide the programme design (6).
Data Collection
We conducted 9 semi-structured interviews with healthcare managers on the IMPACT programme between July 2018 and April 2019. We used purposive sampling to ensure that there was a representative and qualified sample (7). The interviewer was a doctoral researcher with a background in clinical medicine (OL), who also observed three programme workshops. Interviews lasted between 25 and 60 minutes and were digitally recorded and manually transcribed. The interview schedule was piloted with one of the programme faculty before use and is included as supplementary material. We identified themes from the data using inductive thematic analysis (8). We adopted a pragmatist approach throughout, focusing on developing insights with practical implications for leadership development and change management (9). After we completed thematic analysis, we presented the themes at a subsequent programme workshop and invited participant comments and feedback.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
4. Characteristics of participants [Table 1]
Table 1: Characteristics of participants (N=9)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
5. Results
We conducted nine interviews and manually transcribed interview recordings, amounting to more than 180 pages of transcribed interview data. These findings were presented to the whole cohort during one of the final programme workshops, and agreed to be representative of the cohort as a whole.
Defining success
Interviewees reported four factors that define a successful leadership development course, as presented in Table 2: changing their own/team attitudes and behaviours; creating new connections; involving a practical application of skills learnt; and demonstrating long-term results.
Change in Attitudes and Behaviours
Participants identified change in attitudes and behaviours as core success factors. They particularly focused on the need to build confidence amongst attendees, and noted that behavioural change following a programme was a defining marker of programme success. Peer or team perceiving changes to their leadership style were also highlighted as an important outcome for a successful programme.
“I think on a personal level a leadership program is something where you emerge at the end of 12 months changed from how you entered it. You have been personally challenged. You have reflected on the way you do things and how you make something happen and you have done a bit of soul searching and emerged a different leader at the end of it. That's what success is.” (Manager E)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Development of new connections and networks
Development of new professional and social connections with seniors, peers, and the larger team was also seen as a key outcome for healthcare leadership programmes. They saw these new connections as being important for contextualising, understanding and normalising challenges, as well as being important for developing insights into possible new approaches.
“So I’ve met some really interesting people [within the same organisation]. Who have similar models and similar issues that they're trying to create and solve. And actually you realise we're all trying to do the same things.” (Nurse A)
Changes in Behaviour
Participants also emphasised the need for programmes to result in practical changes in behaviour. They saw changes in behaviour as both short and long term outcomes, and emphasised the need for successful programmes to achieve both short term changes in behaviour (such as application of skills into projects) as well as longer term outcomes that persist after the end of the programme.
“I would expect them to come back and tell me what new skills they've found or they have learnt. And how they were going to implement them, and again which areas may benefit from that.” (Manager B)
Long-term Results
Although immediate system results were important to participants, there was an understanding amongst participants that demonstrating long-term results is more important than short-term results from a successful programme.
“Some of the things you learn are difficult to obviously display. But I think when you invest in a tier of people, what you want is I suppose some of that tier to actually graduate forward and then either go into more senior posts outside of the organisation or more hopefully inside the organisation.” (Doctor B)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Delivering success
Interviewees described three key areas of focus for delivery of success in healthcare leadership development programmes: programme design components, tailoring of methods and content to participant needs, and positive participant perceptions of relevance to them.
The programme design components participants described as necessary for success fall into four areas: programme goal clarity, mixed team membership during the programme, time for reflection, and creation of a productive learning space free from distractions by restricting use of technology (emails).
Programme Design: Clarity of Programme Goals
Clarity of programme goals was highlighted as a factor determining participant engagement, at both an individual level (defining participant goals) as well as at a programme level (the goals that the programme is trying to achieve for teams and for the organisation). Participants emphasised that programmes need to be tailored to the problem at hand.
“Firstly to have an identified change that can be measurable. So a change within whatever environment or whatever structure that we're living in. Improved teamworking, not measurable. Improved self fulfillment, not measurable. So i think in many ways the non-measurable are much enormous value than the measurable. Because certainly I felt that having my first experience of investment in myself as a leader, I found that very powerful.” (Doctor A)
Programme Design: Mixed Team Membership
Many participants emphasised the need for mixed disciplinary backgrounds in the programme to allow for inter-disciplinary and inter-industry learning (from speakers outside healthcare) that is directly applicable into mixed-discipline working environments like healthcare.
“For me to really engage, I needed to have that triumvirate [of different disciplines in the programme].” (Doctor C)
“Perhaps from a different angle from a different time position. Something clicks. And makes different sense in a different environment.” (Manager C)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Programme Design: Time for reflection
Participants emphasised the need for time for reflection on learning and the creation of a forum for self-reflection. They described working in environments where there is little time and space for meaningful reflection, and described having an environment on the programme where they had enough time, space and psychological support to reflect as being essential for a successful programme.
“You've been on a good course or you've got good leadership… if you can actually get them to stop and think. You might not always get them to change ultimately. But as long as you get them to keep stopping and reflecting, And be prepared to discuss, I think again that's a good sign.” (Manager B)
Programme Design: Freedom from distractions
Similarly citing work pressures, several interviewees described the need for a space where they were free from the distractions of work. They specifically mentioned that having a space where their use of technology, internet and emails was restricted, so that they were able to justify (to themselves and to their teams) being less available for communication during the workshops.
“And so that just feels really healthy, being able to sort of step away and look at the trust stepped away and having that day away from what we're doing. It's very hard to concentrate on anything when… You know, the bleep goes off, people need you.” (Nurse A)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Tailoring Methods and Content to Participant Needs
In addition to noting specific educational or structural requirements for successful programmes, participants also tended to focus on the need to tailor a programme’s design to the needs of the participants on the programme. They commented on the importance of including speakers with leadership expertise and internal speakers with organisational connections and understanding; formalisation of processes related to application of the skills on the programme and participant goal-setting, and inclusion of coaching/mentoring. In addition to methods, several participants brought up organisational and healthcare finances as a core curriculum area that they perceived most participants to need support in developing.
“There needs to be a clear contract at the beginning about what people want to get out of it and what the program can deliver. So if there's a mismatch between, on either side then they don't tend to work as well.” (Manager E)
External speakers were valued as being able to provide new insights and novel approaches to leadership, though participants emphasised the need for all speakers to have good understanding of the constraints present within healthcare. Internal speakers were seen as providing an assurance that the executive team and senior management were invested in the leadership development process, and facilitating development of connections and networks.
“For me a leadership programme that would be more successful would be a leadership program that isn't just with NHS staff” (Nurse A)
The only area which recurred for curriculum content required for success was financial literacy. Participants described having considerable financial and resource restrictions in their roles, and not enough understanding of organisational and healthcare finances to be able to work within those restrictions. The need for improved financial literacy was highlighted as a particular point of weakness for doctors, by the doctors themselves as well as by the other members of the triumvirates.
“Unless somebody has a particular background in it, I think it's true to say that doctors don't do finance very well. It's not part of their curriculum. They never really hold a budget... ever. And actually, we've got to start thinking about why is what is best for patients not the best for the finances and what is best value for money? We can spend millions and do awesome things, but actually will that give us any better outcomes, benefits. As a system. Trying to get people to understand that.” (Doctor B)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
Positive Participant Perceptions of the Programme
Positive perception of the programme was tied into the perceived relevance of the leadership programme to attendees. A positive experience was suggested as a proxy for a successful programme and was justified by one participant with the difficulty of assessing results.
“The only way it can measure itself within a year is… did those people feel that the course was advantageous to them? Great. Then that's worth another year.” (Manager C)
There was a recognition that many individuals in healthcare, particularly doctors, will have minimal prior experience with formal leadership development, and that the content in a programme like this needs to be appropriate and engaging for triumvirates with mixed experience and ability.
“So i've been doing a leadership role for nine years. We haven't really, well I haven't been invited to, or exposed to any sort of leadership program support in that time.” (Doctor B) “I took on the… lead role but I had no training whatsoever for that” (Doctor A)
Concerns were raised with the stigmatising effect of teams being chosen for a programme seen as remedial. Future programmes need to consider the messaging and language used to justify attendance on the programme, ensuring this is positive.
“I think it's making sure that the message is, that this isn't for the naughty teams. This is also for the good teams. So that's the sort of relevant bit I suppose, it's just getting that message.” (Doctor C)
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
6. Perceptions of leadership development programmes [Table 2]
Table 2: Perceptions regarding Leadership Development.
Codes are collected under the themes of defining success from leadership development programmes and the actionable requirements for this success to be achieved.
Macro-codes are listed with micro-codes in italics.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
7. Discussion
By interviewing participants in a senior healthcare leadership development programme, we were able to identify important ways that these participants defined success, alongside factors which the participants thought were necessary for a programme to deliver success. Participants defined leadership development success in terms of changed participant attitudes, changed own/team behaviours, creation of new connections, demonstration and practical application of skills learnt, and demonstration of long-term results. Our participants also noted several educational design components that were important for success, including having mixed professional backgrounds on the programme, and they emphasised the need to tailor methods and content to participant needs.
The ways our participants defined success align with the Kirkpatrick et al. (10) framework for training outcomes, wherein positive perceptions, behavioural change, and clear outcome improvements define leadership development success. Our findings concerning the added value of external faculty support the findings of a recent systematic review by (5), which highlighted the value of having mixed faculty. Participant preference for having a range of professional backgrounds in their leadership development cohort also aligns with recent work by Frich and Spehar (11), and the need for protected time away alongside coaching and mentoring aligns with [results from] Stewart-Lord et al. (12). While our research generally aligned with recent work suggesting learning methods were more important than specific content (5), our interviewees suggested that it is important to include training in finances for participants who were not familiar with finances in their day-to-day work. They otherwise emphasised the need to tailor content for participant needs to ensure that the programme can cover areas with which they might need particular support and to promote a sense of programme relevance.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
We were surprised to note that financial literacy was the one area of curriculum content that participants suggested is necessary for successful leadership development programmes in healthcare. This has previously been highlighted in surgical leadership development by Jaffe et al. (13) but has not been a focus of NHS leadership development programmes to date, which have tended to focus on other content related to leadership theory, behaviours, communication and such (14). Greater value seems to be attributed by our interviewees to skills-based knowledge acquisition, with attitudinal/behavioural/practical change perceived as more important than theory-based knowledge acquisition. We were interested to find that concerns about financial literacy related most to the doctors on the programme, which aligns with findings from Spehar and colleagues, that doctors tend to be less well-prepared for transitions into clinician-manager roles (15).
Hospital service delivery pressures meant that we were only able to interview nine of the 25 programme participants. To check that these findings were representative of the views of the participants on the programme we presented the themes back to the whole cohort for their feedback, as described above.
In this paper we have identified and highlighted the importance of tailoring an evaluation to programme goals, and of including skills-based outcomes from healthcare leadership development programmes. We have also highlighted core design features that participants on senior healthcare leadership development programmes consider essential for success, including positive participant experiences, a programme structure that actively supports reflective and practical learning, and tailoring methods to the needs of the participants.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
8. Implications for programme design
Our findings have several implications for programme design:
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
9. Ethics and Funding
Ethical considerations
The Clinical Trial & Research Governance Group (CTRG) at the University of Oxford approved an ethics exemption for this study as a ‘service evaluation project’ (ref: IMPACT Programme Evaluation). Written consent to participate in the study was obtained from all study participants.
Contributors OL, collected data. OL, RN, and AH contributed to analysis, writing and editing. RN and IS edited and reviewed the manuscript.
Funding OL was supported during this work by a Rhodes Scholarship.
Competing interests None declared.
Patient consent for publication Not required.
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Title: IMPACT - how to design & deliver a leadership development programme for senior healthcare leaders.
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